‘Should I take the Pill the “morning after”?’ Some considerations

It has finally arrived. Neofarma Pharmaceuticals, the undisputed winner in the much hotly debated question of whether emergency contraceptives should be available in local pharmacies or not, has announced that “the long-awaited morning-after pill” is now available over-the-counter, that is, without medical prescription, for women of child-bearing age. As of December 14 2016, Neofarma Pharmaceuticals is distributing in local pharmacies an ulipristal acetate emergency contraceptive, (trade name ellaOne) authorized under EU law, but a levonorgestrel based emergency contraceptive, recently authorized by the local medicines authority, (trade name Levonelle) should also be available soon.

As emergency contraception is now (more) readily available, it is a matter for the individual woman to decide—and presumably, solely with the help of a pharmacist—whether or when, and specifically which kind of the so-called “morning-after pill” is appropriate for her use. And the decision will not be merely a medical one, but a moral one.

Making use of emergency contraception is not like popping in paracetamol versus an anti-inflammatory to fix aches and pains. No one would deny that the intent to manage pain effectively is a reasonable one; thus one only needs medical—not moral—advice to determine which painkiller is most effective for one’s particular condition. Yet, the woman considering emergency contraception is not trying to fix a medical ailment, but to undo the possible effects of a prior moral action. So why a woman desires to make use of emergency contraception is as important as what medical and biological (side)effects a particular chemical that is ingested might have—effects that might not just concern the individual woman, but also her possible offspring. So how is the woman—and her pharmacist?—to sort through all issues that intermingle the medical with the moral?

The first key question is the obvious one. Why is a woman seeking to take a high dose of synthetic hormones to prevent conception after engaging in unprotected sexual intercourse during the very small timeframe when she suspects she is potentially fertile? Is it because the sex was not with the “right” partner? Maybe because casual sex turned out to be not so “casual” when the partner refused to use protection? Maybe because the partners in a stable relationship agree that it is not the right time—or the right decision, possibly even for health reasons—to have a child, but something went wrong with their usual method of contraception? Maybe because the woman had no choice in the matter and she was forced to have sex?

The stories are many. The point is that not all intents carry the same moral meaning. A woman who has been raped has a right to defend herself against a potential pregnancy from her aggressor. A woman who engages regularly in unprotected sex with complete strangers is not only a health hazard—not just to herself, but to society at large—but emergency contraception can hardly be repeatedly recommended to fix what is really a behavioural, and therefore moral, issue.

But assuming that the intent behind the decision to take emergency contraception is a reasonable one, let’s say, the extreme case of rape, there is still the question of means. In this case, while a woman who has been raped has a right to not have to suffer the additional trauma of a possible pregnancy through an act of violence, if a child has already been conceived, the child herself or himself has a right to life and to good health. So deciding on the appropriate means to prevent conception (and only conception) implies knowing how the particular active ingredient in the “emergency contraceptive” works—and how it works at different points in the woman’s cycle.

One would think that this should be a relatively straightforward matter, since one would expect science (and the pharmaceutical companies producing the medicinals) to provide all the relevant information related to their use. Yet much of the confusion surrounding the public debate on the “morning-after pill” arises precisely because it is the science that is not at all clear.

Scientific research on how the “more effective” and already available in local pharmacies, ulipristal acetate works to bring about a woman’s next period is still in its early stages. It suggests that, unlike levonorgestrel, the drug prevents ovulation even when this is just about to happen. But its success at bringing about the next menstration is so high that it seems unlikely that it only acts to prevent ovulation. Hence, many scientists are cautious about its possible post-fertilization effects, in particular for the transportation of the zygote in the fallopian tube prior to implantation. If a new life begins at conception, and ulipristal acetate is “effective” at bringing about the next period by doing more than preventing fertilization, then, when taken at different times in a woman’s cycle, in fact it could act not just as a “contraceptive”, but as an “abortifacient” as well.

More research has been done on levonorgestrel, since its use internationally is still much more common. But even here, scientific literature is not conclusive. It seems likely that the drug acts primarily, though less effectively than ulipristal acetate, by preventing ovulation. But if ovulation has occurred and a zygote has possibly formed, some scientists advice caution, since no research has conclusively shown that a potential embryo in its earliest stages would not be harmed through exposure to the synthetic hormone. In other words, while the scientific opinion is that levonorgestrel acts primarily as a contraceptive, the literature has not concluded that it always acts only as a contraceptive. As the United States Catholic Bishops recommend, in the case of rape, levonorgestrel can be administered to a woman if the process of her monthly ovulation has not started. But if ovulation, and therefore possibly conception, have already occurred, then there is no point in administering an “emergency contraceptive.” Indeed, it is safer—morally and medically—to not do so at all.

A chemical marketed as an “emergency contraceptive,” should be precisely that and only that: a means to prevent ovum from meeting sperm with no further effects. It is not a magic bullet to make sure one gets their next period instead of a “positive” on the pregnancy stick. For between taking an emergency contraceptive after unprotected sex and seeing the next menstrual flow, a lot could happen in the complex ecosystem that is a woman’s reproductive system. Even more, a lot could happen that science still has no adequate way of actually monitoring or understanding fully. But having the right medical information—information that pharmaceutical companies have little economic interest to research and make publicly available—is precisely what is necessary for the woman to make a truly “informed” decision.

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